An audit of the moderate to severe acute head injury patients in Chris Hani Baragwanath Academic Hospital

Objectives: Head injury is a devastating condition in developing countries like South Africa, contributing significantly to mortality and morbidity. The various factors affecting outcome like age, gender, mechanism of injury, clinical, radiological findings and treatment is reported. Their relation to outcome (Glasgow Outcome Score) of treatment in Chris Hani Baragwanath Academic hospital is analyzed. Methods: This is a retrospective, descriptive and demographic profile study. The sample group consists of moderate to severe head injury patients admitted in the neurosurgical unit of Chris Hani Baragwanath Academic hospital from January 2011 to June 2012. The data includes age, gender, nature of head injury (scalp, skull, intracranial), mode of injury (fall from height, road traffic accident, fire arm injury, assault, blast injury), condition at presentation [Glasgow Coma Scale (GCS)], pupillary reaction, Computed Tomography (CT) scan findings, treatment received and outcome [Glasgow Outcome Score (GOS)] of treatment. Results: A total of 292 patients was enrolled in the study, 258 males (88.3%) and 34 females (11.6%). In the age distribution 50 patients were below 19 years, 161 patients were between 20 to 39 years, 60 patients 40 to 59 years and 21 patients above 60 years. The various mechanisms of injury noted were assault in 127 patients, pedestrian vehicular accident in 50 patients, motor vehicular accident in 33 patients, motor bike accidents in 4 patients, train accidents in 2 patients, gunshot injury in 6 patients, fall from height in 35 patients and struck by heavy object in 5 patients.123 patients had a GCS between 3-5, 72 patients GCS between 6-8 and 97 patients GCS 8-12. 192 patients had equal and reacting pupils after the head injury, 52 patients unilateral fixed pupils and 10 patients bilateral fixed pupils. The Computed tomography (CT) of the brain showed 287 patients with focal intracranial findings, 107 with diffuse brain injury and 168 patients with features of raised intracranial pressure. 129 patients (44.1%) were surgically treated and 163 patients (55.8%) treated conservatively with medical treatment. The variables age, mechanism of injury, GCS, pupillary reaction, raised intracranial pressure and type of management was compared to GOS and found to be statistically significant. Conclusions: The outcome of patients with moderate to severe head injury has no effect on gender but has a significant relationship between age and mortality. The mechanism of head injury has a direct effect on the prognosis with gunshot head having the worst outcome. The important prognostic factors affecting the outcome include: age of patients, severity of head injury (GCS), pupillary reactivity to light and the pathology of the brain CT scan. The unfavorable prognostic factors are: old age, non-reacting pupils to light, severe head injury (low GCS) and raised ICP after head injury. Medical or surgical management have similar mortality rate.Submitted in fulfillment for the requirements of the degree of Master of Medicine in Neurosurgery Faculty of Health Science University of Witwatersran

Prognosis in traumatic brain injury

Introduction: The general purpose of this thesis was to study prognosis in traumatic brain injury (TBI) patients, with the aim of providing useful and practical information in clinical practice and clinical research. The specific objectives were: to develop and validate practical prognostic models for TBI patients and to assess the validity of the Modified Oxford Handicap Scale (mOHS) for predicting disability at six months. Methods: A survey was first conducted to understand the importance of prognostic information among physicians. A systematic review of prognostic models for TBI patients was then carried out. Prognostic models were developed using data from a cohort of 10,008 TBI patients (CRASH trial) and validated in a cohort of 8,509 TBI patients (IMPACT study). Two focus groups and a survey were conducted to develop a paper-based prognostic score card. The correlation between the mOHS and the Glasgow Outcome Scale (GOS) was assessed, the validity of different mOHS dichotomies was assessed, and the discriminative ability of the mOHS to predict GOS was evaluated. Results: Doctors considered prognostic information to be very important in the clinical management of TBI patients, and believed that an accurate prognostic model would change their current clinical practice. Many prognostic models for TBI have been published, but they have many methodological flaws which limit their validity. Valid prognostic models for patients from high income countries and low & middle income .countries were developed and made available as a web calculator, and as a paper based score card. The mOHS was strongly correlated with and was predictive of GOS at six months. Conclusion: The prognostic models developed are valid and practical to use in the clinical setting. The association between mOHS and GOS suggest that the mOHS could be used for interim analysis in randomised clinical trials in TBI patients, for dealing with loss to follow-up, or could be used as simple tool to inform patients and relatives about their prognosis at hospital discharg

Design and Analysis of Randomized and Non-randomized Studies: Improving Validity and Reliability

The aim of the thesis is to investigate how to optimize the design and analysis of randomized and non-randomized therapeutic studies, in order to increase the validity and reliability of causal treatment effect estimates, specifically in heterogeneous diseases. The following research questions will be addressed: __1)__ What are the benefits of more advanced statistical analyses to estimate treatment effects from RTCs in heterogeneous diseases? a. What is the heterogeneity in acute neurological diseases with regard to baseline severity and further course of the disease? b. What is the potential gain in efficiency of covariate adjustment and proportional odds analysis in RCTs in Guillain-Barré syndrome (GBS)? __2)__ What is the validity and reliability of the RD design compared to an RCT to estimate causal treatment effects? a. What are threats to the validity of the RD design to estimate treatment effects compared to an RCT? b. How efficient is the RD design to estimate treatment effects compared to an RCT? c. What are the potential benefits of an alternative assignment approach in an RD design

Mortality risk stratification after traumatic brain injury and hazard of death with titrated hypothermia in the Eurotherm3235Trial

OBJECTIVES: Hypothermia reduces intracranial hypertension in patients with traumatic brain injury but was associated with harm in the Eurotherm3235Trial. We stratified trial patients by International Mission for Prognosis and Analysis of Clinical Trials in [Traumatic Brain Injury] (IMPACT) extended model sum scores to determine where the balance of risks lay with the intervention. DESIGN: The Eurotherm3235Trial was a randomized controlled trial, with standardized and blinded outcome assessment. Patients in the trial were split into risk tertiles by IMPACT extended model sum scores. A proportional hazard analysis for death between randomization and 6 months was performed by intervention and IMPACT extended model sum scores tertiles in both the intention-to-treat and the per-protocol populations of the Eurotherm3235Trial. SETTING: Forty-seven neurologic critical care units in 18 countries. PATIENTS: Adult traumatic brain injury patients admitted to intensive care who had suffered a primary, closed traumatic brain injury; increased intracranial pressure; an initial head injury less than 10 days earlier; a core temperature at least 36°C; and an abnormal brain CT. INTERVENTION: Titrated Hypothermia in the range 32-35°C as the primary intervention to reduce raised intracranial pressure. MEASUREMENTS AND MAIN RESULTS: Three hundred eighty-six patients were available for analysis in the intention-to-treat and 257 in the per-protocol population. The proportional hazard analysis (intention-to-treat and per-protocol populations) showed that the treatment effect behaves similarly across all risk stratums. However, there is a trend that indicates that patients in the low-risk group could be at greater risk of suffering harm due to hypothermia. CONCLUSIONS: Hypothermia as a first line measure to reduce intracranial pressure to less than 20 mm Hg is harmful in patients with a lower severity of injury and no clear benefit exists in patients with more severe injuries

Severe head trauma in children: Analysis of 68 cases in light of current guidelines

Aim: To assess the characteristics of severe head trauma in the pediatric age group and to analyze its results under the currentguideline.Material and Methods: Eighty pediatric patients (<18 years) admitted to our hospital with the diagnosis of severe head trauma andtreated by neurosurgery and the pediatric intensive care unit (ICU) between 2014 and 2018 were analyzed retrospectively. Of these,68 patients who met the study criteria were selected. Besides the demographic data of the patients, the presenting neurologic, clinic,radiologic and laboratory findings were recorded. Then the association between these variables and 1-year Glasgow Outcome Scale(GOS) scores was analyzed.Results: There is a correlation between the presenting GCS scores and 1-year GOS scores of the patients when grouped as favorable(4-5) and unfavorable (1-3). Regarding the other admission findings, the patients with hypothermia, the patients with hyperglycemia,the patients to whom CPR was applied, the patients with pupillary areflexia, the patients with hypoxia and the patients with neurologicaldeterioration have lower 1-year GOS scores. There was no difference between the gender, age, type of injury, type of trauma (isolatedhead trauma or multiple trauma), presence of shock on admission, having hematoma surgery, having decompressive craniectomy,treatment with ICP monitoring and 1-year GOS scores. The overall mortality rate was 29.4% (20 patients), and the rate of poorprognosis (GOS 1-3) was 48.5% (33 patients).Conclusion: Children with severe head trauma should be treated at centers that are experienced in the field per updated guidelines.Since the morbidity and mortality rates of severe head trauma are still high, efforts toward improving preventive measures shouldalso be considered